P - 76576REQUEST FOR ELECTRICAL INSPECTION
1� 7 8 1� 9 2 O 2 Minnesota Board of Electricity �q� `'
❑ 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �: ;
(651) 642-0800 TTY/MRS 1-800-627-3529 x�ww.electriciry.stute.mn.us
Describe -using the back of the white copy if ne - the �p�grk �e d by (�i st
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GENERAL FEES Outdoor Lighting Standard $1
SERVICES I POWER SUPPLIES Traffic Siqnal Standard (�a $5
0 to 200 Am ere $5 �C F T`
Above 200 Am ere $10
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Eaeh Svstem Device or Apparatus (cil $.50
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Lighting Retrofit @ $.25 per Fixture
Center Pivot Irriaation Boom (� $40
Transformers u to 10 KVA $10
Transformers over 10 KVA @$ 20
Transformer I Power Supply for Signs I Outline Lighting @$5
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additional Insoection Tri�s (� $20
Fee
TOTALFEE �(j�Q(�
total fee is $20)
I insoected the electrical installation described herein on the dates stated:
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S cial lnspection $30 per Hour exaiaeo nenNOONeo onre
Special Inspection $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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I �aie: Rou h-in Ins ection Re uired? ❑Yes ;
, 1 fi�t��� g p q �]No InspectionOtherThanRough-In: �ReadyNow�WillCall
i You must call the inspector when ready! I, Date Ready:
I certify that I am the Cx] LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
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��, OwnedOccupant Name
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'�, Electrical Utilijt�y [('�
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ISection ;I Range
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'��. Electrical Utility Address
Fire No. County
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Please Provide Two (2) Phone Numbers I
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'� Gontractor / Gompany Name 'i Contractor License Number I Master Electrician or Power Limited Technician
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I Mading Address (Contractor, �Company or Owner Performing Installation)
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I Authorized Si nature (Coniractor or Owner Performing Installation) ' Please Provide Two (2) Phone Numbers Induding Area Code I
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